Colo-umbilical enterocutaneous fistula as a rare complication of diverticulitis of the sigmoid colon / Fístula enterocutánea sigmoidea umbilical como una rara complicación de una diverticulitis del colon sigmoide

Abstract The care of patients with enterocutaneous fistula constitutes a significant challenge owing to the alterations it usually brings about. For successful treatment, it is necessary to manage fluids and electrolytes adequately, provide practical nutritional support, and control sepsis until its eradication; thus, many fistulae close spontaneously. We present the case of a 36-year-old male patient with a four-month history of fecal-like umbilical secretion. When performing the fistulogram, we confirmed a fistulous tract of 9 cm, which ended at the level of the sigmoid colon, a rare location. In cases where the enterocutaneous fistula does not close, and surgical treatment is indicated, it is imperative to maximize perioperative care, decrease surgical time, choose the correct surgical technique, and prepare the patient for surgery to avoid complications with a fatal outcome.

Resumen La atención de los pacientes con fístula enterocutánea constituye un gran reto, por las alteraciones con las que suelen acompañarse. Para lograr un tratamiento exitoso es necesario realizar un adecuado manejo de los líquidos y electrolitos, brindar un apoyo nutricional eficaz y controlar la sepsis hasta lograr su erradicación; de esta manera, muchas fístulas cierran espontáneamente. Se expone el caso de un paciente de 36 años de edad, con un cuadro de secreción umbilical de aspecto fecaloideo de 4 meses de evolución. Al realizar la fistulografía se constató un trayecto fistuloso de 9 cm, el cual terminaba a nivel del colon sigmoide, localización poco frecuente. En los casos en que la fístula enterocutánea no cierre y tenga indicación de tratamiento quirúrgico, es necesario extremar los cuidados perioperatorios, minimizar el tiempo quirúrgico, elegir la técnica quirúrgica correcta y preparar al paciente para la cirugía, de modo que se eviten complicaciones que pueden tener un desenlace fatal.

Tratamento Endoscópico de Deiscências de Anastomose Esofágica em Pacientes Oncológicos - Série de Casos / Endoscopic Treatment of Esophageal Anastomotic Leaks in Oncological Patients - Case Series

"Introdução: Deiscência de anastomose (DA) esofágica após esofagectomia ou gastrectomia total é uma complicação pós-operatória grave e uma das principais causas de morbimortalidade. Intervenções endoscópicas vem sendo utilizadas de maneira crescente em pacientes com DA, atualmente constituindo a primeira linha de terapia. Objetivos: Determinar a segurança e eficácia do tratamento endoscópico da DA esofágica após a cirurgia para o câncer esofagogástrico e destacar as suas melhorias recentes. Metodologia: Coleta de dados retrospectivos de pacientes com deiscências de anastomose esofágica após tratamento cirúrgico do câncer gastroesofágico que foram submetidos a tratamento endoscópico no INCA no período de janeiro de 2016 a fevereiro de 2019. Os tratamentos endoscópicos incluíram: (1) passagem de prótese metálica autoexpansível (PMAE) e (2) aplicação de terapia de pressão negativa (TPN). Após a coleta e análise dos dados foi realizada uma revisão da literatura para proporcionar uma comparação dos resultados obtidos. Resultados: Ao todo, 9 pacientes com deiscência de anastomose esofágica foram tratados com intervenção endoscópica. A idade média foi de 61 anos (variação: 50-69 anos). Dos 9 pacientes, 7 realizaram tratamento neoadjuvante. Sete cirurgias foram realizadas com intenção curativa e em dois casos foi realizada ressecção R2. O diâmetro do orifício fistuloso variou desde 2mm até deiscência quase completa da anastomose. O intervalo entre a identificação da deiscência e o tratamento endoscópico variou de 0 a 33 dias (média de 10 dias). A passagem de PMAE foi realizada em 7 pacientes, sendo 5 parcialmente e 2 totalmente recobertas. TPN foi o método de escolha em 2 casos. Ao todo, o tratamento endoscópico foi bem-sucedido em 7 pacientes (77.8%), sendo 5 (71%) nos casos de PMAE e 2 (100%) nos casos de TPN. Conclusão: DAs esofágicas após cirurgia de câncer de esôfago e estômago podem ser manejadas com sucesso e segurança com a terapia endoscópica. A TPN desponta como terapia inovadora, com resultados muito promissores. Novas terapias endoscópicas demonstraram segurança e estão constantemente criando evidências de eficácia em relação ao tratamento cirúrgico"(AU)

"Introduction: Esophageal anastomotic leaks (AL) after esophagectomy or total gastrectomy is a serious postoperative complication and one of its main causes of morbidity and mortality. Endoscopic interventions have been increasingly used in patients with AL, currently constituting the first line of therapy. Objectives: To determine safety and efficacy and to highlight recent improvements in the management of esophageal AL after surgery for esophageal and gastric cancer. Methodology: We retrospectively collected data of patients with esophageal anastomosis leaks after surgical treatment of gastroesophageal cancer who underwent endoscopic treatment at INCA from January 2016 to February 2019. Endoscopic treatments included: (1) passage of self-expandable metal stents (SEMS) and (2) application of endoscopic vacuum therapy (EVT). After data collection and analysis, a review of the literature was performed to provide a comparison of the results obtained. Results: Nine patients with esophageal anastomosis dehiscence were treated with endoscopic intervention. The mean age was 61 years (range: 50-69 years). Of the 9 patients, 7 underwent neoadjuvant treatment. Seven surgeries were performed with curative intent and in two cases R2 resection was performed. The diameter of the fistulous orifice ranged from 2mm to almost complete dehiscence. The interval between the identification of the leak and the endoscopic treatment ranged from 0 to 33 days (mean: 10 days). The SEMS passage was performed in 7 patients of whom 5 received a partially covered and 2 received a fully covered stent. EVT was the method of choice in 2 cases. Endoscopic treatment was successful in 6 patients (77.8%), 5 (71%) in the SEMS group and 2 (100%) in the EVT group. Conclusion: Esophageal AL after surgery for esophageal and stomach cancer may be, in most cases, successfully and safely managed with endoscopic therapy. EVT emerges as an innovative therapy, with very promising results. New endoscopic therapies have shown safety and are constantly creating evidence of efficacy in relation to surgical treatment"(AU)

Desarrollo e implementación de un nuevo diseño de stent de nitinol para el manejo de estenosis y fístulas benignas del tracto digestivo / Development and Implementation of a New Nitinol Stent Design for Managing Benign Stenoses and Fistulas of the Digestive Tract

Antecedentes: las estenosis benignas, la ruptura del tracto digestivo y las fístulas digestivas son condiciones que ponen en riesgo la vida y que por lo general son tratadas quirúrgicamente. Ahora, ha surgido la colocación de stents metálicos parcial o totalmente cubiertos como una opción de manejo con mínima invasión. Se pretende determinar la efectividad clínica de un nuevo diseño de stent de nitinol totalmente cubierto para el tratamiento de las perforaciones digestivas y las fístulas anastomóticas, con especial énfasis en la evaluación de la hiperplasia reactiva. Métodos: en el período 2012-2013 se colocó un stent de nitinol autoexpandible totalmente cubierto en 15 pacientes con perforaciones benignas de esófago, fístulas anastomóticas, estenosis después de cirugía gastrointestinal alta o baja. Se utilizó un stent de mayor diámetro en su centro (20 mm) y en su porción proximal (28 mm). Se recolectaron datos demográficos, tipo de lesión, ubicación del stent y remoción, éxito clínico y complicaciones. Resultados: a un total de 15 pacientes se les puso 15 nuevos stents por fístulas anastomóticas (n = 8), estenosis esofágica (n = 2), estenosis en anastomosis colorrectal (n = 2), estenosis de anastomosis gastroyeyunal (n = 1), ruptura iatrogénica de esófago (n = 1), y estenosis pilórica (n = 1). La remoción endoscópica del stent fue exitosa en todos los pacientes, y una fue particularmente difícil por hiperplasia reactiva. El éxito clínico se logró en 9 pacientes (73%), con una media de permanencia del stent de 10 semanas (rango 7 a 12 semanas). En total, ocurrieron 7 complicaciones en 15 pacientes (47%): hiperplasia reactiva (n = 1), migración (n = 3), dolor severo (n = 2), ulceración esofágica (n = 1), y solo 1 paciente requirió cirugía después del fallo del stent. Ningún paciente falleció como consecuencia de la colocación del mismo. Conclusiones: un stent totalmente cubierto, con nuevo diseño, dejado por 10 semanas, puede ser una alternativa ...

Background: Benign stenoses, digestive tract ruptures and fistulas are conditions that endanger life and are often treated surgically. Recently, the placement of partially or fully covered metal stents has emerged as a minimally invasive treatment option. This article looks at a new design for stents to determine its clinical effectiveness. The new stent is a completely covered nitinol stent for treatment of gastrointestinal perforations and anastomotic leaks. This article places special emphasis on evaluating reactive hyperplasia. Methods: Fifteen had the new completely covered self-expanding nitinol stent placed for treatment of benign esophageal perforations, anastomotic leaks, and stenoses following upper or lower gastrointestinal surgery during 2012 and 2013. The stents are 20 mm in diameter in the middle and 28 mm in diameter at the proximal end. Information about patient demographics, type of lesion, lesion locations, stent removal, clinical success and complications was collected. Results: A total of 15 stents were placed in 15 patients to treat anastomotic leaks (n = 8), esophageal stenoses (n = 2), colorectal stenoses (n = 2), a gastrojejunostomy stenosis (n = 1), an esophageal iatrogenic rupture (n = 1), and a pyloric stenosis (n = 1). Endoscopic removal of the stent was successful in all patients. Although it was particularly difficult in one case because of reactive hyperplasia. Clinical success was achieved in nine patients (73%). Average duration of time between stent placement and removal was 10 weeks with a range of 7 to 12 weeks. In total, seven complications occurred in 15 patients (47%): reactive hyperplasia (n = 1), migration (n = 3) severe pain (n = 2) esophageal ulceration (n = 1) only one patient required surgery after stent failure. No patients died as the result of stenting. Conclusions: A redesigned completely covered stent kept in place for 10 weeks may be an alternative to surgery for treating gastrointestinal ...

Systematic review of cyanoacrylate embolization for refractory gastrointestinal fistulae: a promising therapy.

BACKGROUND: Surgical management of gastrointestinal fistulae has been reported to carry a 30-day morbidity rate up to 82% and a mortality rate ranging from 2% to 4.8%; thus nonoperative alternatives are required. The aim of the present study was to assess the current experience on the use of cyanoacrylates in the management of these fistulae. METHODS: A systematic review was carried out on Medline, Embase, The Cochrane database, Academic Search Complete, MedicLatina, and SciELO for English, Spanish, and Portuguese articles dealing with refractory fistulae by means of cyanoacrylate embolization therapy. Publication dates were restricted from 1969 to present. Outcome parameters were study design, number of participants, etiology of the fistula, approach, material used, success rate, complications, and mortality. RESULTS: Electronic search yielded a total of 377 articles. After a meticulous screening, only 14 studies dealing with foregut/midgut fistulae and 6 addressing hindgut fistulae were included. All the included articles were prospective and retrospective case series. Cumulative success rate was 81% (range 0% to 100%) and 3 out of 203 patients (1%) developed minor complications. CONCLUSION: Cyanoacrylate embolization of nearly all types of refractory gastrointestinal fistulae is a feasible and harmless technique. Prospective controlled studies are required to support the available evidence.

Descripción epidemiológica y tratamiento de los pacientes con enfermedad de Crohn / Epidemiological description and treatment of Crohn's disease patients

Antecedentes: la enfermedad de Crohn es un proceso inflamatorio crónico granulomatoso que puede afectar todo el tracto digestivo. Se diagnostica cada vez más frecuentemente en nuestro medio, y es causa importante de morbimortalidad en los pacientes afectados. El presente estudio tiene como objetivo conocer la prevalencia de esta enfermedad, sus manifestaciones clínicas más frecuentes, los diversos tratamientos utilizados y la respuesta a estos. Métodos: se revisaron los expedientes clínicos de todos los pacientes con diagnóstico de enfermedad de Crohn evaluados durante 2009 en el Servicio de Gastroenterología de un centro de salud terciario, el Hospital "Dr. Rafael A. Calderón Guardia". Resultados: de un total de 28 pacientes con enfermedad de Crohn, solo tres casos fueron diagnosticados en la década 1990-2000, mientras que los restantes 25 casos fueron diagnosticados de 2001 a 2009. Un 60 por ciento de los casos diagnosticados corresponden a pacientes del sexo masculino. La población estudiada tiene una distribución de edades entre los 17 y 72 a¤os, con un promedio de edad de 39 años de edad. El 82 por ciento de los pacientes se encuentran con tratamiento de mantenimiento con base en derivados del ácido 5-aminosalicílico, mientras que un 62 por ciento también utiliza azatiprina, 6-mercaptopurina o metotrexate, un 51 por ciento reciben esteroides sistemáticos y solo siete pacientes recibieron inflimixab. Un 68 por ciento de los pacientes del presente estudio requirió manejo quirúrgico en algún momento de su evolución, y en un 96 por ciento de los pacientes se logró remisión de la enfermedad. Conclusión: la prevalencia de la enfermedad de Crohn parece encontrarse en aumento, y en los casos en los cuales hay fallo terapéutico al régimen farmacológico, puede ser necesario un abordaje quirúrgico...